British Journal of Anaesthesia 115 (2): 194202 (2015)

doi: 10.1093/bja/aev199
Advance Access Publication Date 23 June
2015 Review Article

Impact of metabolic syndrome in surgical patients:

should we bother?
P. Tzimas1,*, A. Petrou1, E. Laou1, H. Milionis2, D.
P. Mikhailidis3 and G. Papadopoulos1
1
Department of Anaesthesia and Postoperative Intensive Care, School of Medicine,
University of Ioannina, Ioannina University Campus, Stavros Niarchos Ave., Ioannina
45110, Greece, 2Department of Internal Medicine, School of Medicine, University of
Ioannina, Ioannina University Campus, Stavros Niarchos Ave., Ioannina 45110, Greece,
and 3Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal
Free Hospital Campus, University College London Medical School, University College
London (UCL), Pond Street, London NW3 2QG, UK
*Corresponding author. E-mail: petzimas@gmail.com; ptzimas@cc.uoi.gr

Abstract
Clinicians inevitably encounter patients who meet the diagnostic criteria for the metabolic
syndrome (MetS); these criteria include central obesity, hypertension, atherogenic
dyslipidaemia, and hyperglycaemia. Regardless of the variations in its denition, MetS may be
associated with adverse outcomes in patients undergoing both cardiac and non-cardiac surgery.
There is a paucity of data concerning the anaesthetic management of patients with MetS, and
only a few observational (mainly retrospective) studies have investigated the association of
MetS with perioperative outcomes. In this narrative review, we consider the impact of MetS on
the occurrence of perioperative adverse events after cardiac and non-cardiac surgery.
Metabolic syndrome has been associated with higher rates of cardiovascular, pulmonary, and
renal perioperative events and wound infections compared with patients with a non-MetS
prole. Metabolic syndrome has also been related to increased health service costs, prolonged
hospital stay, and a greater need for posthospitalization care. Therefore, physicians should
be able to recognize the MetS in the perioperative period in order to formulate management
strategies that may modify any perianaesthetic and surgical risk. However, further research is
needed in this eld.

Key words: anaesthesia; metabolic syndrome; postoperative outcome; surgical procedures

(high triglyceride and low high-density

Editors key points lipoproteincholesterol concentrations), high
In this narrative review, the authors describe the metabolic syndrome, outlining
fasting its impactconcentration,
glucose and its recognition. and central
They outline management strategies and call for further research in this area.
obesity. 1
Metabolic syndrome is associated with
an increased risk for cardiovascular disease
and type 2 diabetes mellitus. 2 Moreover, MetS
has been associated with an increased risk of
non-cardiac vascular diseases, including
stroke, carotid artery disease, peripheral
artery disease, chronic kidney disease,
atherosclerotic renal artery stenosis, and
2
abdominal aortic aneurysms.
Metabolic syndrome (MetS) comprises a group of
risk factors that include high blood The denition of MetS relies on clinical and
pressure, atherogenic dyslipidaemia laboratory criteria and has been the subject of
controversy.3 The rst attempt to

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194
 Metabolic syndrome and surgical
patients | 195

dene MetS came in 1998 from the World Health

MetS, while the percentage in Southeast Asia is
Organization.1 Insulin resistance was suggested less than one- fth, and this can be
to be the major underlying risk factor and a attributed in part to differences in the
prerequisite for the diagnosis.1 Nowadays, a median age of Asian and European populations.9
gen- erally accepted denition is the one that In China, the prevalence is relatively low in
came from the American Heart the general population, and in Japan, it
Association/National Heart, Lung, and Blood varies considerably according to each study.9
4
Institute Scientic Statement. It involves the Metabolic syndrome is considered a
following ve diagnostic criteria, any three of constellation of patho- physiological
which constitute the diagnosis of MetS: in- processes. Currently, it is primarily thought to
creased waist circumference, elevated be caused by adipose tissue dysfunction and
triglycerides, reduced high-density insulin resistance, which is associated with
5 abnormalities in insulin secretion, re- ceptor
lipoproteincholesterol, elevated blood
pressure, and elevated fasting glucose (Table signalling, and impaired glucose disposal.
1). Some individuals or ethnic groups (e.g. Visceral or intra-abdominal fat is also known
Asians, especially South Asians) appear to be to secrete free fatty acids and potentially
suscep- tible to development of MetS at waist harmful concentrations of cytokines, such as
circumferences below those presented in Table tumour necrosis factor, leptin, resistin, and
1, which mostly refers to populations in in- plasminogen activator inhibi- tor, which in
dustrialized countries.6 Although the turn promote insulin resistance.10 11 They might
International Diabetes Fed- eration denition also initiate a prothrombotic12 and pro-
13
initially considered central (abdominal) inammatory state that has been reported in
obesity as a sine qua non risk factor for patients with MetS.14 High blood pres- sure and
establishing the diagno- sis of MetS, both the dyslipidaemia are well documented and modiable
International Diabetes Federation and the risk factors for atherosclerotic vascular
American Heart Association/National Heart, Lung, disease. It is unclear whether environmental
and Blood In- stitute nally agreed that factors, genetic predisposition, or both are
abdominal obesity should not be a pre- also involved. One key feature of MetS is that
requisite feature but rather one of the ve each diagnostic compo- nent may not stand out
equally balanced diagnostic criteria of MetS.6 on its own because it is not markedly
Metabolic syndrome has a high prevalence abnormal. However, when these relatively minor
worldwide that may vary according to the set of abnormalities occur together, there is a
diagnostic criteria used (current or older).7 It substantially increased risk of vascular
is more prominent in countries with Western events. The presence of MetS has been associated
life- styles, affecting around 3439% of the with a high risk of vascular and metabolic
adult population in the USA with roughly equal complications (e.g. future develop- ment of
prevalence in men and women.8 In Eur- ope, diabetes mellitus) independently of its
approximately one-quarter of the adult individual diag- nostic features. Therefore,
population has the identication of subjects with MetS
warrants a holistic management of coexisting
risk factors, which is considered the
preferable strategy rather than targeting
Table 1 Criteria for clinical diagnosis of metabolic syndrome
(at least three are required). *Waist circumference is measured with a tape in a horizontal plane around the abdomen at the superior point of the iliac crest as dened by the
the pathophysiology of MetS is not yet fully
understood, there are concerns of an increased
Clinical measureCategorical cut-of points perioperative risk because of the co-
Waist circumference*102 cm in men (European, Caucasian,88 cm in women USA, Canada)
morbidities associated with this syndrome,
Triglycerides which represent a challenge for the
anaesthetist.
The aim of this narrative review is to provide

an overview of comes in patients undergoing

cardiac and non-cardiac surgery.

150 mg dl1 (1.7 mmol l1)
or
Search methods
On drug treatment for elevated triglycerides
<40 mg dl1 (1.0 mmol l1) in men
We searched
<50 mgMEDLINE up to
dl1 (1.3 mmol l1) October
in women 1, 2014 for
High-density
relevant orpublica-lipoprotein
tions using combinations of
the cholesterol
On drug treatment
keywords, such foras low high-density
metabolic lipoprotein-
syndrome,cholesterol
outcome, 130 mm Hg systolic blood
perioperative pressure
complications, surgery,
mor- or
tality, morbidity, colon cancer, rectal
cancer, 85 mm Hg
liver diastolic blood
surgery, ortho- pressure
paedic surgery,
or
total joint arthroplasty, risk factors, and
spinal On antihypertensive drug treatment in a patient with a history of hyperte
100 mg dl1 (5.6 mmol l1) or
On drug
tiedBlood
and treatmentthose
selected for elevated
we glucose
judged relevant.
pressure
These were included in this narrative review.

Metabolic syndrome and cardiac surgery

Incidence of metabolic syndrome in cardiac
surgery patients
The estimated prevalence of MetS in cardiac
surgery patients is fairly high (nearly 46%).15
16
This incidence is almost double that found
in the general population (2328%).17 18

Hypertension is commonly a diagnostic feature

Fasting glucose
196 | Tzimas
et al.
of MetS in cardiac surgery patients (up to
85%).15 Not all cardiac surgery patients
diagnosed with the MetS are obese, but the
majority appear to be at least overweight and
have increased waist circumference.6 In a retro-
spective study15 of 5304 patients, only 46.5% of
those who met the criteria for MetS had a BMI
>30 kg m2, while 12.9% were nor- mal weight
(18.5<BMI<24.9); the rest (40.4%) were
overweight.15
Of note, almost one-third to one-half of those
diagnosed with MetS and who undergo coronary
artery bypass grafting (CABG) surgery are also
15 16
diabetic. A prospective study19 including 100
patients demonstrated a similar incidence of
obesity (57.5% with BMI >30 kg m2) and diabetes
mellitus (DM; 45%) among patients with MetS.
not change the severity of the aortic stenosis
(in terms of mean gra- dient and aortic valve
area), it signicantly affects the preopera- tive
left ventricular remodelling in these patients
and increases

Metabolic syndrome and mortality in cardiac surgery

patients
Metabolic syndrome seems to be an independent
predisposing fac- tor for mortality after CABG
surgery.20 21 In the retrospective ana- lysis of
5304 cardiac surgery patients,15 those with MetS
had a 2.4% mortality rate compared with 0.9% for
those without MetS. In multivariate analysis,
patients with MetS had a three-fold in- creased
probability of death.15 This increased mortality
occurred irrespective of gender and the presence
(2.71 vs 0.21%, P<0.0001) or absence of DM (2.04
vs 1%, P=0.014), and in this study, DM was not
shown to increase overall mortality in the
absence of MetS. An observational report studied
long-term mortality among 1183 CABG patients and
found that MetS increases all-cause and cardiac
mortality only in non-diabetic patients (hazard
ratio 1.34, P=0.028 and 2.31, P=0.002,
respectively).16 Conversely, the survival of dia-
betic patients was not affected by the presence
of MetS.16 This study used a BMI >25 kg m2
instead of waist circumference for assigning
patients to the MetS group, and it is unclear
whether this modication affected the results. In
both retrospective studies, causes of death were
also not different between those with and
without MetS.15 16 A small prospective study failed
to detect any difference in mortality between
those with and without MetS.19

Metabolic syndrome and morbidity in cardiac

surgery patients
Regarding complications rate, it appears that
patients with MetS are more prone to develop
renal failure or infection ( pneumonia,
mediastinitis, or wound infection), compared with
those without MetS.15 19 In one study, patients
with MetS had a higher incidence of perioperative
stroke (2.3 vs 1.4%, P=0.014) and similar rates
of perioperative myocardial infarction (based on
elevations of creatine kinase-MB or troponin I
concentrations) compared with patients without
MetS.15 It also seems that patients with MetS
have a higher risk for either pre- or
postoperative atrial b- rillation (AF) and
present increased perioperative resistance to in-
sulin and postoperative cognitive dysfunction
compared with patients without MetS (see the
section entitled Specic anaes- thetic
considerations in the management of surgical
patients with metabolic syndrome).

Metabolic syndrome and valvular decay

One important aspect of MetS is a tendency to
accelerated devel- opment of a pressure
gradient in both native and bioprosthetic
2224
valves. When studying the progression of
aortic stenosis in patients with MetS (using a
BMI >30 kg m2 instead of waist cir-
cumference), it was reported that stenosis
2
advanced more quickly (0.14 vs 0.08 cm yr1,
P=0.008, respectively) than in those with- out
MetS.22 Metabolic syndrome was an independent
predictor of rapid progression of aortic
stenosis in terms of aortic valve area and peak
gradient, and the relative risk of this adverse
outcome was 3.85 in patients with MetS
compared with those without MetS. Other
investigators reported that although MetS does
the incidence of postoperative AF.25 Another Metabolic syndrome and non-cardiac
study26 showed that the relative risk for
aortic valve calcication was 1.49 for women surgical procedures
and 1.70 for men with MetS compared with those Metabolic syndrome may have a negative impact
without MetS. on outcomes after non-cardiac procedures and
Investigating the progression of aortic increases the risk of adverse peri- and
bioprosthetic valve stenosis retrospectively,23 postoperative events.
one study found that patients with MetS
presented a more rapid increase of
transprosthetic gradient compared with those Metabolic syndrome and general surgery
without MetS (4 [ 5] vs 2 [ 2] mm Hg yr1,
P<0.001, respectively when evaluated 3 yr after Based on available data, MetS signicantly
surgery), a more frequent worsening of affects mortality and morbidity rates in general
prosthetic aortic insufciency (25 vs 12%, surgery patients. A retrospective study28
respectively) and worse valve haemodynamics evaluated 3973 patients included in the National
(41 vs 25%, P=0.02, respectively).23 Surgical Quality Improvement Program database
who underwent liver resection. This study
A small retrospective study demonstrated
assessed the impact of MetS on the compli- cation
that at 4.5 yr after mitral bioprosthetic
rate and 30 day mortality. The presence of MetS
valve implantation, patients with MetS had
increased transprosthetic valve gradients was asso- ciated with an increased risk of
postoperative death [odds ratio (OR) 2.7, 95%
(6.8 vs 4.7 mm Hg, P=0.007, respectively)
24 condence interval (CI) 1.54.8; P=0.001)]. The
compared with those without MetS. cumu- lative incidence of death was 6.9 deaths
per 1000 person-days among patients with MetS
Metabolic syndrome and stroke compared with 2.6 deaths per 1000 person-days
One study,27 which investigated risk factors among those without MetS.28 Metabolic syndrome
for postoperative stroke after cardiac is also related to an increased risk of
surgery, conrmed that among others, two risk postoperative complica- tions. Specically,
factors of MetS (diabetes and hypertension) patients with MetS were at greater risk for
were independ- ent risk factors for stroke.27 infectious, pulmonary, and cardiac complications
Echahidi and colleagues15 reported a (OR 1.4, 95% CI 1.021.8; P=0.04).28 Furthermore,
signicantly increased rate of stroke (2.3 vs in elective surgery under gen- eral anaesthesia
1.4%) and renal failure (12.4 vs 6.8%) in the frequency of hypotension, hypoxaemia,
patients with MetS undergoing CABG compared hypertension, bleeding, pain, and postoperative
with those without MetS. nausea and vomiting is increased (OR 3.31; 95% CI
In summary, patients undergoing cardiac 1.76.4; P<0.05) in patients with MetS (case
surgery are more likely to have MetS, with or control study, 150 MetS patients, 150 control
without obesity and DM. Cardiac sur- gery subjects, P<0.0001).29
patients with MetS have higher morbidity and The MetS group (n=42, 36.8%) of 114 patients
mortality than those without MetS, and they who underwent elective resection of colorectal
are more likely to develop peri- and cancer experienced a higher rate of
postoperative complications. However, larger postoperative complications and a longer length
prospect- ive studies are needed in order to of hospital stay than the non-MetS group (40.5
form a denitive opinion. vs 11.1%, P<0.001; 11.2 vs
8.1days, P<0.006, respectively). It is incidence of PE (2.7%, 95% CI 1.84.0%) than
important to mention that MetS as an entity patients without MetS (1.3%, 95% CI 1.01.6%,
P=0.001), and after adjusting for all other
signicantly predicted poor surgical outcomes;
signicant risk factors, patients with MetS still
this was not true for any of its individual had 1.6 times (95% CI 1.012.56; P=0.043) greater
components.30 odds for developing PE than those without MetS.
According to the largest retrospective study31 Notably, the increasing number of MetS
based on data components signicantly augmented the incidence of
from 310 208 patients from the American College PE by 23% for each additional com- ponent of
of Surgeons National Surgical Quality MetS. The most important MetS component was
Improvement Program database, patients with MetS
(dened as the coexistence of obesity,
hypertension, and DM) undergoing non-cardiac
surgery are at increased risk for mor- tality,
cardiac adverse events, pulmonary
complications, acute kidney injury, stroke and
coma, wound complications, and post- operative
sepsis. In that study, patients underwent
general, vascu- lar, or orthopaedic surgery
between 2005 and 2007. Specically, patients
with the modied MetS experienced nearly two-
to three-fold higher risk of cardiac adverse
events, a 1.5- to 2.5-fold higher risk of
pulmonary complications, a two-fold higher risk
of neurological complications, and a three- to
seven-fold higher risk of acute kidney injury
compared with patients of normal weight.31

Metabolic syndrome and vascular interventions

Vascular interventions are of specic interest
and should be con- sidered as high-risk
procedures according to the European Soci- ety
of Anaesthesiology and Cardiology
34
guidelines. 32 The prevalence of MetS is
considerable in patients with vascular dis-
ease (>30% in patients with carotid artery
disease;35 >50% in those with peripheral
arterial disease)36 and seems to affect mor-
tality and adverse event rates depending on the
type of vascular surgery. A retrospective study
described the effect of MetS on the outcomes in
921 patients who underwent carotid endarterec-
tomy or carotid stenting.35 Patients with MetS
were more likely to experience a complication
than non-MetS patients (23 vs 14%, P=0.001).
There was no difference between MetS and non-
MetS patients with respect to patency,
restenosis, re-interven- tion, or survival, but
a difference existed for freedom from stroke,
myocardial infarction, and major adverse events
as evaluated by KaplanMeier analysis. Of note,
the presence of DM was asso- ciated with higher
rates of major adverse events and myocardial
infarction in MetS patients compared with the
non-MetS group.35 Smolock and colleagues37
studied 738 patients undergoing supercial
femoral artery interventions for symptomatic
lower extremity arterial disease. They found
that the overall mortality was higher in the
MetS group, with patient survival rates of 71
( 2) and 53 ( 3)% at 5 yr in the non-MetS and
MetS groups, re- spectively. Thirty day major
adverse cardiac events were equiva- lent, but
the incidence of 30 day major adverse limb
events was higher in the MetS group compared
with the non-MetS group.37

Metabolic syndrome and orthopaedic surgery

Metabolic syndrome may predict adverse outcomes
in major orthopaedic surgery. Common
perioperative complications after total joint
arthroplasties (TJA) include pulmonary embolism
(PE), deep vein thrombosis, wound infection, and
cardiovascular events.3840 An increased risk for
PE has been recognized in patients who
fullled modied MetS criteria and underwent
total hip and knee replacement. In one study,
patients with MetS had a signicantly higher
obesity, based on BMI (because waist with non-MetS patients. Patients with MetS
circumference values were lacking).41 were more often discharged to another health-
care facility than to their home. Median
Retrospective studies42 43
observed an hospital charges were also higher for MetS vs
increased incidence of in-hospital major non-MetS patients for posterior lumbar spine
complications and signicantly higher median
fusion.44
hospital charges43 in MetS compared with non-
MetS patients. Surprisingly, the mortality
was lower in the MetS group in one of these Metabolic syndrome and bariatric surgery
43
studies, while the other study did not
Bariatric surgery is an acceptable and effective
comment on mortality.42 Likewise, a higher rate method to man- age obesity-related co-
of perioperative cardiovascu- lar
complications (AF, pulmonary oedema, morbidities in morbidly obese patients.45 46
arrhythmias, brady- cardia, and cardiac According to the current guidelines, bariatric
arrest) were observed in patients with MetS surgery should be considered in subjects with a
after TJA compared with those without MetS.42 A BMI 35 kg m2 in the presence of metabolic
multivariate logistic regression model disease including type 2 diabetes mellitus and
adjusting for age, sex, race, surgery type, MetS.47 Nearly four in ve patients undergoing
and the presence of risk factors (coronary bariatric surgery present with MetS.48 Co-
artery disease, congestive heart failure, morbidities (cardiac, pulmonary, metabolic, and
cerebrovascular disease, and thrombo- embolic hepatic) and complications of morbid obesity
disease) revealed that the risk of in individuals undergoing bariatric surgery may
cardiovascular compli- cations after TJA was vary and include multiple sys- tems,49 thus
signicantly higher in patients with MetS posing particular challenges to the
(P=0.017, OR 1.64, 95% CI 1.092.46).42 It has anaesthetist.50 Hypertension, dyslipidaemia, and
also been reported that patients with hyperglycaemia (i.e. the key components of
uncontrolled diabetes, hypertension, or dysli- MetS) respond to bariatric surgery.47 A recent
pidaemia (as components of MetS together with retrospective study on the largest cohort to
a BMI >30 kg m2) have increased risk of date of bariatric sur- gery patients did not
perioperative complications and in- creased reveal increased rates of perioperative com-
length of hospital stay after TJA. The rate of plications in obese patients with MetS
postoperative complications was signicantly compared with those without MetS.48
greater in the uncontrolled MetS group (48.6%)
than in the well-controlled MetS group (7.9%,
P<0.0001). Patients with uncontrolled MetS Specic anaesthetic considerations in
required a mean hos- pital stay of 7.2 days
(95% CI 5.29.0) compared with 4.0 days (95% the management of surgical patients
CI 3.64.3) for patients with controlled MetS with metabolic syndrome
(P<0.0001).40
In patients who underwent primary posterior Metabolic syndrome and atrial brillation
lumbar spine fusion surgery, the MetS was
identied as a risk factor for peri- operative Atrial brillation is common after cardiac
life-threatening complications, increased surgery. It carries almost double the morbidity
cost, longer in-hospital stay, and non-routine and mortality rate of postoperative
discharge. Specically, patients
experienced myocardial infarction,
with MetS
cardiac BARU TRANSLATE SAMPE
complica- tions, pneumonia, and pulmonary
complications more frequently when compared
SINI !!!!!!!!!
cardiac patients without AF51 and has a In a small prospective study of 56 cardiac
signicant impact on hospitalization costs.52 surgery patients (28 with and 28 without MetS)64
Metabolic syndrome has been associated with and 28 coronary patients who did not undergo
increased incidence of AF in the general surgery, verbal and non-verbal memory and
population.53 54 One study53 reported 60 events executive function were assessed. Patients with
per 10 000 person-yr in MetS patients and 36 MetS had lower scores both before and 1 week
events in patients with no MetS during 15 yr after surgery compared with
follow-up. They calculated that if MetS could
be eliminated with appropriate treatment, as
many as 22% fewer AF events would have occurred.
In cardiac surgery, AF affects approximately
one-third of post- operative cardiac patients
(1140% after CABG and almost 50% after valve
surgery).5557
The pathophysiological link between MetS and
AF has not been dened. It is speculated that
electrical imbalance, which re- presents the
functional component of atrial remodelling,
might be targeted by certain factors. In
cardiac surgery patients, these could include
the increased free fatty acids generated
during the lipolytic process as a result of
perioperative stress in addition to the
inammatory processes linked to cardiopulmonary
bypass and the inammatory component of the
MetS per se.52 58 59
Echahidi and colleagues,52 in a retrospective
study (5085 car-
diac patients), found that AF was slightly more
common (29 vs 26%) in those with MetS according
to National Cholesterol Educa- tion Program-Third
Adult Treatment Panel criteria than those
without MetS, and the incidence increased
progressively in paral- lel with their BMI. Older
patients (>50 yr old) presented a signi- cantly
higher incidence of postoperative AF (29 vs 8%)
compared with the younger patient group (<50 yr
old). In the older patient group, obesity (BMI
>30 kg m2) and not MetS was found to be sig-
nicantly associated with AF, whereas in younger
patients the presence of MetS doubled the rate
of new-onset postoperative AF (from 6 to 12%,
P=0.01). Other researchers found contrasting
effects of DM and MetS on postoperative AF after
60
cardiac sur- gery. Hurt and colleagues60 showed
that MetS was not individu- ally predictive of
postoperative AF, but DM appeared to be the
decisive factor contributing independently to
increased post- operative incidence of AF.

Metabolic syndrome and intraoperative hyperglycaemia

Glycaemic control is an important component of
perioperative management. While the avoidance
of signicant hypergly- caemia may decrease
perioperative morbidity and mortality, irre-
spective of the existence of an established
diagnosis of DM, concerns have been raised that
strict glycaemic control might in- crease
morbidity and mortality mainly as a result of
perioperative hypoglycaemia and stroke.61 A
small prospective study in cardiac patients
revealed that only those with MetS presented
signi- cantly enhanced perioperative insulin
resistance that was accompanied by
signicantly higher values of C-reactive pro-
tein.62 The authors imply a parallel involvement
of inammation and the adverse metabolic state
of MetS in the development of insulin
resistance. Clinicians should be alert with
regard to potentially detrimental effects of
immediate postoperative hypoglycaemia as a
result of intense intraoperative insulin
63
treatment.

Metabolic syndrome and cognitive dysfunction

There is some evidence that postoperative
cognitive function is adversely affected by the
presence of MetS in cardiac surgery patients.
those without MetS or no surgery, especially Non-alcoholic fatty liver disease is
in recent verbal memory tests (P<0.02).64 associated with fat accu- mulation in the liver
Besides, cognitive functions appear also to and insulin resistance and is considered to be
be more profoundly affected in subjects with the hepatic manifestation of the MetS.72 73 In
MetS com- pared with their healthier this regard, preoperative low-energy diet
counterparts after non-cardiac surgery.65 appears to reduce liver size and facilitate
The results outlined above are documented the surgical procedure when surgery must be
in a rat model. Using this model, MetS per- formed on morbidly obese patients.74 A
produced greater memory impairment and short-term (4 weeks) low-carbohydrate diet has
persistent learning and memory decline after been proved to be an effective treat- ment
tibial fracture surgery under isourane strategy for patients with non-alcoholic fatty
anaesthesia.66 liver disease undergoing mainly bariatric
surgery or any foregut operations.75 There is
evidence that active smoking is associated with
Potential treatment options for patients with the development of MetS, whereas smoking
cessation appears to reduce the risk of the
metabolic syndrome who will require surgery syndrome.76 Indeed, plasma concentrations of
Available evidence3 31 suggests that MetS adiponectin, an adipocyte-derived plasma
provides a useful tool to recognize surgical protein that is closely related to insulin
patients at increased risk of peri- and post- sensitivity and MetS,77 increase after smoking
operative complications. However, there is a cessation.78 Current smoking is also associated
paucity of data showing that potential with an elevated risk of mortality in
interventions could improve surgery out- come patients undergoing major surgery,79 while
in patients with MetS. discontinuation of smoking before surgery has a
Given that obesity and smoking are main favourable impact on perioperative outcome.80
causes of prevent- able mortality,67 Consequently, smoking cessation counselling and
therapeutic lifestyle changes, incorporating interventions should be im- plemented before
in- tense behavioural intervention to reduce surgery for all smokers with metabolic distur-
weight and improve tness level, are bances, such as diabetes, obesity, or
advisable in overweight or obese subjects.68 69 dyslipidaemia.81
These interventions could be implemented long Untreated hypertensive subjects have an
before planned surgery in patients with MetS, increased risk for peri- operative stroke,
though their benet may not be easily myocardial ischaemia, and renal failure. 32 8284
quantied. Preoperative nutrition therapy While hypertension is not a strong independent
(including cal- orie restriction and low- predictor for perioperative cardiovascular
carbohydrate consumption) may be con- sidered events in the general population cohort, it is
in order to prepare patients metabolically for recommended that effective blood pressure
the surgical stress; however, the duration and control improves the perioperative risk prole
specic measures regarding nutrition need by reducing the extent of target organ damage
further investigation. 70 In orthopaedic (i.e. heart failure, stroke, and renal dysfunc-
surgery, preoperative assessment of nutrition tion).32 85 Lifestyle changes, including at least
and optimization of nutri- tional parameters, 30 min moderate aerobic exercise (brisk
including tight glucose control and targeted walking, cycling etc.) 34 days per week may
weight loss, may reduce the risk of
perioperative complications, including improve blood pressure and glycaemic control.86
88
71
infection.
 Disorders of haemostasis have been documented reports, and may be higher in cardiac surgery
in subjects with MetS.12 Indeed, coagulation is patients.
enhanced in MetS because of the increased Several, but not all, studies that evaluated
plasma concentrations of brinogen, tissue the impact of MetS on cardiac and non-cardiac
factor and factor VII, which are related to surgery have shown increased mor- tality among
inammation and central obesity. 12 89
92
These patients with MetS. Most evidence shows that
abnormalities, combined with the de- creased MetS adversely affects perioperative outcomes in
brinolytic activity, in patients with MetS both cardiac
contribute to a greater risk of thrombotic
events (arterial and venous).93 94 Diet and
lifestyle changes can affect coagulation and
brinoly- sis.95 However, we need to establish
whether commonly used medications (e.g.
antihypertensive agents and statins) inuence
haemostasis in patients with MetS. Obesity and
insulin resist- ance enhance platelet activity
in subjects with MetS.12 96 Finally, the surgical
procedure per se is associated with platelet
activa- tion.97 Discontinuation of
antithrombotic drugs because of con- cerns
regarding perioperative bleeding in patients
with MetS may carry an even greater thrombotic
risk. This is of major im- portance in patients
with previous coronary stenting.98 There- fore,
it is advisable that antithrombotic treatment
should be tailored according to the estimated
risk of surgical bleeding vs thrombotic
complications.
Statins are the principal lipid-lowering
agents. Their protect- ive role exceeds their
ability to change blood lipid concentra-
tions.99 These agents appear to have favourable
pleiotropic effects on vascular endothelial
function, atherosclerotic plaque stability,
inammation, and thrombosis.100 101 There is no
con- clusive evidence or guidelines regarding
the appropriate time to initiate statin therapy
before an elective surgical procedure in
statin-naive patients with MetS. However, based
on current evi- dence for patients undergoing
vascular surgery102 we suggest that statins
should be started as soon as possible in
statin- naive patients with MetS (at least 2
weeks before elective high- risk procedures in
order to take advantage of their benecial
extralipid actions). Patients already on a
statin should continue treatment throughout
the peri- and postoperative periods as soon
as oral therapy is recommenced. The intensity
and duration of statin treatment in the
perioperative period needs to be inves-
100 103
tigated.
The administration of statin therapy (loading
dose) in the con- text of percutaneous coronary
interventions104 or vascular sur- gery105 has
been shown to affect outcome favourably.
Statins should be administered to all patients
with vascular disease, whether they are
managed conservatively or are undergoing an
106 107
open surgical or endovascular procedure.
Furthermore, periprocedural statin
administration may help to prevent con- trast-
induced acute kidney injury in patients
undergoing angiog- raphy, with or without
intervention.108

Limitations of this review

Our review should be considered in the light of
certain limita- tions. It is a narrative
review, including mostly retrospective
observational studies. Moreover, heterogeneity
was considerable because of different study
outcomes and populations, and diverse
methodological processes.

Concluding remarks
Metabolic syndrome has a high prevalence
among surgical patients, exceeding 40% in some
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probably contri- butes to even more DP. Meta-
perioperative events, with the most common bolic syndrome and non-cardiac vascular
being cardiac, pulmonary, renal, diseases: an up- date from human studies.
cerebrovascular, thrombo- embolic, sepsis,
Curr Pharm Des 2013; 20: 494452
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Authors contributions metabolic syndrome: a joint interim
statement of the Inter- national Diabetes
Study planning: P.T., H.M., G.P. Federation Task Force on Epidemiology and
Manuscript preparation: P.T., A.P., E.L., Prevention; National Heart, Lung, and Blood
H.M., D.P.M. Analysis and interpretation of Institute; American Heart Association; World
data: P.T., D.P.M., G.P. Data collection: Heart Federation; Inter- national
A.P., E.L. Atherosclerosis Society; and International
Manuscript approval: all authors. Associ- ation for the Study of Obesity.
Circulation 2009; 120: 16405
7. Athyros VG, Ganotakis ES, Tziomalos K, et al.
Declaration of interest Comparison of
None declared. four denitions of the metabolic syndrome in a
Greek (Medi- terranean) population. Curr Med
Res Opin 2010; 26: 7139
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